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      Early Continuous Renal Replacement Therapy in Cardiogenic Shock Patients with Severe Acute Kidney Injury Undergoing Extracorporeal Membrane Oxygenation

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          Background: Continuous renal replacement therapy (CRRT) may benefit patients requiring extracorporeal membrane oxygenation (ECMO). However, the clinical benefits and timing of CRRT have not been fully elucidated for these patients. Methods: This study was conducted retrospectively at the Taipei Medical University Hospital between January 2008 and December 2010. We included patients who had Acute Kidney Injury Network (AKIN) stage 3 disease at the initiation of ECMO and subsequently underwent CRRT. We excluded patients aged <18 years or those who were chronic dialysis patients. Early dialysis was defined as receiving CRRT <24 h after the initiation of ECMO. The primary outcome was mortality before weaning from ECMO. Results: The median age of the 15 patients included in the study was 72 years. The median interval between ECMO and CRRT was 16 h. No significant difference in survival was observed between the early- and late-dialysis patients (p = 0.58, log-rank test). However, a trend toward a shorter mean duration of ECMO therapy was observed in the early-dialysis patients (124 vs. 169 h, p = 0.16). The median follow-up glomerular filtration rate for the survivors was 38.9 ml/min/1.73 m<sup>2</sup>. Conclusion: No survival benefit is conferred by the use of CRRT within 24 h after initiating ECMO in patients with severe acute kidney injury according to AKIN criteria. © 2014 S. Karger AG, Basel

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          Most cited references 29

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          Cardiopulmonary resuscitation with assisted extracorporeal life-support versus conventional cardiopulmonary resuscitation in adults with in-hospital cardiac arrest: an observational study and propensity analysis.

          Extracorporeal life-support as an adjunct to cardiac resuscitation has shown encouraging outcomes in patients with cardiac arrest. However, there is little evidence about the benefit of the procedure compared with conventional cardiopulmonary resuscitation (CPR), especially when continued for more than 10 min. We aimed to assess whether extracorporeal CPR was better than conventional CPR for patients with in-hospital cardiac arrest of cardiac origin. We did a 3-year prospective observational study on the use of extracorporeal life-support for patients aged 18-75 years with witnessed in-hospital cardiac arrest of cardiac origin undergoing CPR of more than 10 min compared with patients receiving conventional CPR. A matching process based on propensity-score was done to equalise potential prognostic factors in both groups, and to formulate a balanced 1:1 matched cohort study. The primary endpoint was survival to hospital discharge, and analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00173615. Of the 975 patients with in-hospital cardiac arrest events who underwent CPR for longer than 10 min, 113 were enrolled in the conventional CPR group and 59 were enrolled in the extracorporeal CPR group. Unmatched patients who underwent extracorporeal CPR had a higher survival rate to discharge (log-rank p<0.0001) and a better 1-year survival than those who received conventional CPR (log rank p=0.007). Between the propensity-score matched groups, there was still a significant difference in survival to discharge (hazard ratio [HR] 0.51, 95% CI 0.35-0.74, p<0.0001), 30-day survival (HR 0.47, 95% CI 0.28-0.77, p=0.003), and 1-year survival (HR 0.53, 95% CI 0.33-0.83, p=0.006) favouring extracorporeal CPR over conventional CPR. Extracorporeal CPR had a short-term and long-term survival benefit over conventional CPR in patients with in-hospital cardiac arrest of cardiac origin.
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            Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients

            Introduction Serum creatinine concentration (sCr) is the marker used for diagnosing and staging acute kidney injury (AKI) in the RIFLE and AKIN classification systems, but is influenced by several factors including its volume of distribution. We evaluated the effect of fluid accumulation on sCr to estimate severity of AKI. Methods In 253 patients recruited from a prospective observational study of critically-ill patients with AKI, we calculated cumulative fluid balance and computed a fluid-adjusted sCr concentration reflecting the effect of volume of distribution during the development phase of AKI. The time to reach a relative 50% increase from the reference sCr using the crude and adjusted sCr was compared. We defined late recognition to estimate severity of AKI when this time interval to reach 50% relative increase between the crude and adjusted sCr exceeded 24 hours. Results The median cumulative fluid balance increased from 2.7 liters on day 2 to 6.5 liters on day 7. The difference between adjusted and crude sCr was significantly higher at each time point and progressively increased from a median difference of 0.09 mg/dL to 0.65 mg/dL after six days. Sixty-four (25%) patients met criteria for a late recognition to estimate severity progression of AKI. This group of patients had a lower urine output and a higher daily and cumulative fluid balance during the development phase of AKI. They were more likely to need dialysis but showed no difference in mortality compared to patients who did not meet the criteria for late recognition of severity progression. Conclusions In critically-ill patients, the dilution of sCr by fluid accumulation may lead to underestimation of the severity of AKI and increases the time required to identify a 50% relative increase in sCr. A simple formula to correct sCr for fluid balance can improve staging of AKI and provide a better parameter for earlier recognition of severity progression.
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              Fluid overload before continuous hemofiltration and survival in critically ill children: A retrospective analysis*

              Continuous venovenous hemofiltration (CVVH) is used for renal replacement and fluid management in critically ill children. A previous small study suggested that survival was associated with less percent fluid overload (%FO) in the intensive care unit (ICU) before hemofiltration. We reviewed our experience with a large series of pediatric CVVH patients to evaluate factors associated with outcome. Retrospective chart review. Tertiary children's hospital. CVVH pediatric ICU patients from November 1997 to January 2003. None. %FO was defined as total fluid input minus output (up to 7 days before CVVH for both hospital stay and ICU stay) divided by body weight. One hundred thirteen patients received CVVH; 69 survived (61%). Multiple organ dysfunction syndrome (MODS) was present in 103 patients; 59 survived (57%). Median patient age was 9.6 yrs (25th, 75th percentile: 2.5, 14.3). Median %FO was significantly lower in survivors vs. nonsurvivors for all patients (7.8% [2.0, 16.7] vs. 15.1% [4.9, 25.9]; p =.02] and in patients with > or =3-organ MODS (9.2% [5.1,16.7] vs. 15.5% [8.3, 28.6]; p =.01). The Pediatric Risk of Mortality Score III at CVVH initiation also was associated with survival in these groups, but by multivariate analysis, %FO was independently associated with survival in patients with > or =3-organ MODS (p =.01). Survival in critically ill children receiving CVVH in this large series was higher than in previous reports. CVVH survival may be associated with less %FO in patients with > or =3-organ MODS. Prospective studies are necessary to determine whether earlier use of CVVH to control fluid overload in critically ill children can improve survival.

                Author and article information

                Cardiorenal Med
                Cardiorenal Medicine
                S. Karger AG
                August 2014
                10 July 2014
                : 4
                : 2
                : 130-139
                Divisions of aNephrology and bCardiology, Department of Internal Medicine, and cDivision of Cardiovascular Surgery, Department of Surgery, Taipei Medical University Hospital, dDepartment of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, and eDivision of Endocrinology and Metabolism, Department of Internal Medicine, Taipei City Hospital, Ren-Ai Branch, Taipei, Taiwan (ROC)
                Author notes
                *Chun-Yao Huang, Division of Cardiology, Department of Internal Medicine, Taipei Medical University Hospital, 252 Wu-Xing Street, Taipei 111, Taiwan (ROC), E-Mail cyhuang@tmu.edu.tw
                364835 PMC4164088 Cardiorenal Med 2014;4:130-139
                © 2014 S. Karger AG, Basel

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                Page count
                Figures: 1, Tables: 3, References: 31, Pages: 10
                Original Paper


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